(a) General provisions--
(1) Purpose.
This section
prescribes guidelines and policies for the delivery and administration
of the TRICARE Dental Program (TDP) of the Uniformed Services of
the Army, the Navy, the Air Force, the Marine Corps, the Coast Guard,
the Commissioned Corps of the U.S. Public Health Service (USPHS)
and the National Oceanic and Atmospheric Administration (NOAA) Corps.
The TDP is a premium based indemnity dental insurance coverage plan
that is available to specified categories of individuals who are
qualified for these benefits by virtue of their relationship to
one of the seven (7) Uniformed Services and their voluntary decision
to accept enrollment in the plan and cost share (when applicable)
with the Government in the premium cost of the benefits. The TDP
is authorized by 10 U.S.C. 1076a, TRICARE dental program, and this
section was previously titled the “Active Duty Dependents Dental
Plan”. The TDP incorporates the former 10 U.S.C. 1076b, Selected Reserve
dental insurance, and the section previously titled the “TRICARE
Selected Reserve Dental Program”, Sec. 199.21.
(2) Applicability.--
(i) Geographic scope.
(A) The
TDP is applicable geographically within the fifty (50) States of
the United States, the District of Columbia, the Commonwealth of
Puerto Rico, Guam, and the U.S. Virgin Islands. These areas are
collectively referred to as the “CONUS (or Continental United States) service
area”.
(B) Extension of the TDP to areas outside the CONUS
service area. In accordance with the authority cited in 10 U.S.C.
1076a(h), the Assistant Secretary of Defense (Health Affairs) (ASD(HA))
may extend the TDP to areas other than those areas specified in
paragraph (a)(2)(i)(A) of this section for the eligible members
and eligible dependents of members of the Uniformed Services. These
areas are collectively referred to as the “OCONUS (or outside the
Continental United States) service area”. In extending the TDP outside
the CONUS service area, the ASD(HA), or designee, is authorized
to establish program elements, methods of administration and payment
rates and procedures to providers that are different from those
in effect for the CONUS service area to the extent the ASD(HA),
or designee, determines necessary for the effective and efficient
operation of the TDP. This includes provisions for preauthorization
of care if the needed services are not available in a Uniformed
Service overseas dental treatment facility and payment by the Department
of certain cost-shares (or co-payments) and other portions of a
provider’s billed charges for certain beneficiary categories. Other
differences may occur based on limitations in the availability and
capabilities of the Uniformed Service overseas dental treatment
facility and a particular nation’s civilian sector providers in
certain areas. These differences include varying licensure and certification
requirements of OCONUS providers, Uniformed Service provider selection
criteria and local results of provider selection, referral, beneficiary
pre-authorization and marketing procedures, and care for beneficiaries
residing in distant areas. The Director, Office of Civilian Health
and Medical Program of the Uniformed Services (OCHAMPUS) shall issue
guidance, as necessary, to implement the provisions of paragraph
(a)(2)(i)(B). Beneficiaries will be eligible for the same TDP benefits
in the OCONUS service area although services may not be available
or accessible in all OCONUS countries.
(ii) Agency.
The provisions
of this section apply throughout the Department of Defense (DoD),
the United States Coast Guard, the USPHS and NOAA.
(iii) Exclusion of
benefit services performed in military dental care facilities.
Except for emergency treatment,
dental care provided outside the United States, services incidental
to noncovered services, and services provided under paragraph (a)(2)(iv),
dependents of active duty, Selected Reserve and Individual Ready
Reserve members enrolled in the TDP may not obtain those services
that are benefits of the TDP in military dental care facilities,
as long as those covered benefits are available for cost-sharing
under the TDP. Enrolled dependents of active duty, Selected Reserve
and Individual Ready Reserve members may continue to obtain noncovered
services from military dental care facilities subject to the provisions
for space available care.
(iv) Exception to
the exclusion of services performed in military dental care facilities.
(A) Dependents who
are 12 years of age or younger and are covered by a dental plan
established under this section may be treated by postgraduate dental
residents in a dental treatment facility of the uniformed services under
a graduate dental education program accredited by the American Dental
Association if
(1) Treatment of pediatric dental patients
is necessary in order to satisfy an accreditation standard of the
American Dental Association that is applicable to such program,
or training in pediatric dental care is necessary for the residents
to be professionally qualified to provide dental care for dependent children
accompanying members of the uniformed services outside the United
States; and
(2) The number
of pediatric patients at such facility is insufficient to support
satisfaction of the accreditation or professional requirements in
pediatric dental care that apply to such programs or students.
(B) The
total number of dependents treated in all facilities of the uniformed
services under paragraph (a)(2)(iv) in a fiscal year may not exceed
2,000.
(3) Authority and responsibility.--
(i) Legislative authority.--
(A) Joint regulations.
10 U.S.C. 1076a authorized
the Secretary of Defense, in consultation with the Secretary of
Health and Human Services, and the Secretary of Transportation,
to prescribe regulations for the administration of the TDP.
(B) Administration.
10 U.S.C. 1073
authorizes the Secretary of Defense to administer the TDP for the Army,
Navy, Air Force, and Marine Corps under DoD jurisdiction, the Secretary
of Transportation to administer the TDP for the Coast Guard, when
the Coast Guard is not operating as a service in the Navy, and the
Secretary of Health and Human Services to administer the TDP for
the Commissioned Corps of the USPHS and the NOAA Corps.
(ii) Organizational
delegations and assignments--
(A) Assistant Secretary of Defense (Health Affairs) (ASD(HA)).
The Secretary
of Defense, by 32 CFR part 367, delegated authority to the ASD(HA)
to provide policy guidance, management control, and coordination
as required for all DoD health and medical resources and functional
areas including health benefit programs. Implementing authority
is contained in 32 CFR part 367. For additional implementing authority
see Sec. 199.1. Any guidelines or policy necessary for implementation
of this Sec. 199.13 shall be issued by the Director, OCHAMPUS.
(B) Evidence of eligibility.
DoD, through
the Defense Enrollment Eligibility Reporting System (DEERS), is
responsible for establishing and maintaining a listing of persons
eligible to receive benefits under the TDP.
(4) Preemption of
State and local laws.
(i) Pursuant to 10
U.S.C. 1103 and section 8025 (fourth proviso) of the Department
of Defense Appropriations Act, 1994, DoD has determined that, in
the administration of 10 U.S.C. chapter 55, preemption of State
and local laws relating to health insurance, prepaid health plans,
or other health care delivery or financing methods is necessary
to achieve important Federal interests, including, but not limited
to, the assurance of uniform national health programs for Uniformed
Service beneficiaries and the operation of such programs at the
lowest possible cost to DoD, that have a direct and substantial
effect on the conduct of military affairs and national security
policy of the United States. This determination is applicable to
the dental services contracts that implement this section.
(ii) Based
on the determination set forth in paragraph (a)(4)(i) of this section,
any State or local law relating to health or dental insurance, prepaid
health or dental plans, or other health or dental care delivery
or financing methods is preempted and does not apply in connection
with the TDP contract. Any such law, or regulation pursuant to such
law, is without any force or effect, and State or local governments
have no legal authority to enforce them in relation to the TDP contract.
(However, DoD may, by contract, establish legal obligations on the
part of the dental plan contractor to conform with requirements
similar or identical to requirements of State or local laws or regulations.)
(iii) The
preemption of State and local laws set forth in paragraph (a)(4)(ii)
of this section includes State and local laws imposing premium taxes
on health or dental insurance carriers or underwriters or other
plan managers, or similar taxes on such entities. Such laws are
laws relating to health insurance, prepaid health plans, or other
health care delivery or financing methods, within the meaning of
the statutes identified in paragraph (a)(4)(i) of this section.
Preemption, however, does not apply to taxes, fees, or other payments
on net income or profit realized by such entities in the conduct
of business relating to DoD health services contracts, if those
taxes, fees, or other payments are applicable to a broad range of
business activity. For purposes of assessing the effect of Federal
preemption of State and local taxes and fees in connection with
DoD health and dental services contracts, interpretations shall
be consistent with those applicable to the Federal Employees Health
Benefits Program under 5 U.S.C. 8909(f).
(5) Plan funds--
(i) Funding sources.
The funds used
by the TDP are appropriated funds furnished by the Congress through
the annual appropriation acts for DoD, the Department of Health
and Human Services and the Department of Transportation and funds
collected by the Uniformed Services or contractor through payroll
deductions or through direct billing as premium shares from beneficiaries.
(ii) Disposition
of funds.
TDP
funds are paid by the Government (or in the case of direct billing,
by the beneficiary) as premiums to an insurer, service, or prepaid
dental care organization under a contract negotiated by the Director,
OCHAMPUS, or a designee, under the provisions of the Federal Acquisition Regulation
(FAR) (48 CFR chapter 1).
(iii) Plan.
The Director,
OCHAMPUS, or designee provides an insurance policy, service plan,
or prepaid contract of benefits in accordance with those prescribed
by law and regulation; as interpreted and adjudicated in accord
with the policy, service plan, or contract and a dental benefits
brochure; and as prescribed by requirements of the dental plan contractor’s
contract with the Government.
(iv) Contracting
out.
The
method of delivery of the TDP is through a competitively procured
contract. The Director, OCHAMPUS, or a designee, is responsible
for negotiating, under provisions of the FAR, a contract for dental
benefits insurance or prepayment that includes responsibility for:
(A) Development,
publication, and enforcement of benefit policy, exclusions, and
limitations in compliance with the law, regulation, and the contract
provisions;
(B) Adjudicating and
processing claims; and conducting related supporting activities,
such as enrollment, disenrollment, collection of premiums, eligibility
verification, provider relations, and beneficiary communications.
(6) Role of Health
Benefits Advisor (HBA).
The HBA is appointed (generally by the commander
of an Uniformed Services medical treatment facility) to serve as
an advisor to patients and staff in matters involving the TDP. The
HBA may assist beneficiaries in applying for benefits, in the preparation
of claims, and in their relations with OCHAMPUS and the dental plan
contractor. However, the HBA is not responsible for the TDP’s policies
and procedures and has no authority to make benefit determinations or
obligate the TDP’s funds. Advice given to beneficiaries by HBAs
as to determination of benefits or level of payment is not binding
on OCHAMPUS or the dental plan contractor.
(7) Right to information.
As a condition
precedent to the provision of benefits hereunder, the Director,
OCHAMPUS, or designee, shall be entitled to receive information
from an authorized provider or other person, institution, or organization
(including a local, State, or United States Government agency) providing
services or supplies to the beneficiary for which claims for benefits
are submitted. While establishing enrollment and eligibility, benefits,
and benefit utilization and performance reporting information standards,
the Government has established and does maintain a system of records
for dental information under the TDP. By contract, the Government
audits the adequacy and accuracy of the dental plan contractor’s
system of records and requires access to information and records
to meet plan accountabilities, to assist in contractor surveillance
and program integrity investigations and to audit OCONUS financial
transactions where the Department has a financial stake. Such information
and records may relate to attendance, testing, monitoring, examination,
or diagnosis of dental disease or conditions; or treatment rendered;
or services and supplies furnished to a beneficiary; and shall be
necessary for the accurate and efficient administration and payment
of benefits under this plan. To assist in claims adjudication, grievance
and fraud investigations, and the appeals process, and before an
interim or final determination can be made on a claim of benefits,
a beneficiary or active duty, Selected Reserve or individual Ready
Reserve member must provide particular additional information relevant
to the requested determination, when necessary. Failure to provide
the requested information may result in denial of the claim and
inability to effectively investigate the grievance or fraud or process
the appeal. The recipient of such information shall in every case
hold such records confidential except when:
(i) Disclosure
of such information is necessary to the determination by a provider
or the dental plan contractor of beneficiary enrollment or eligibility
for coverage of specific services;
(ii) Disclosure of
such information is authorized specifically by the beneficiary;
(iii) Disclosure
is necessary to permit authorized Government officials to investigate
and prosecute criminal actions;
(iv) Disclosure constitutes
a routine use of a routine use of a record which is compatible with
the purpose for which it was collected. This includes a standard
and acceptable business practice commonly used among dental insurers
which is consistent with the principle of preserving confidentiality
of personal information and detailed clinical data. For example,
the release of utilization information for the purpose of determining
eligibility for certain services, such as the number of dental prophylaxis
procedures performed for a beneficiary, is authorized;
(v) Disclosure
is pursuant to an order from a court of competent jurisdiction;
or
(vi) Disclosure by the Director, OCHAMPUS, or designee,
is for the purpose of determining the applicability of, and implementing
the provisions of, other dental benefits coverage or entitlement.
(8) Utilization review
and quality assurance.
Claims submitted for benefits under the TDP
are subject to review by the Director, OCHAMPUS, or designee, for
quality of care and appropriate utilization. The Director, OCHAMPUS,
or designee, is responsible for appropriate utilization review and
quality assurance standards, norms, and criteria consistent with
the level of benefits.
(b) Definitions.
For most definitions
applicable to the provisions of this section, refer to Sec. 199.2. The
following definitions apply only to this section:
(1) Assignment of
benefits.
Acceptance
by a nonparticipating provider of payment directly from the insurer
while reserving the right to charge the beneficiary or active duty,
Selected Reserve or Individual Ready Reserve member for any remaining
amount of the fees for services which exceeds the prevailing fee
allowance of the insurer.
(2) Authorized provider.
A dentist, dental hygienist,
or certified and licensed anesthetist specifically authorized to
provide benefits under the TDP in paragraph (f) of this section.
(3) Beneficiary.
A dependent
of an active duty, Selected Reserve or Individual Ready Reserve member,
or a member of the Selected Reserve or Individual Ready Reserve,
who has been enrolled in the TDP, and has been determined to be
eligible for benefits, as set forth in paragraph (c) of this section.
(4) Beneficiary liability.
The legal obligation
of the beneficiary, his or her estate, or responsible family member
to pay for the costs of dental care or treatment received. Specifically,
for the purposes of services and supplies covered by the TDP, beneficiary
liability including cost-sharing amounts or any amount above the
network maximum allowable charge where the provider selected by
the beneficiary is not a participating provider or a provider within
an approved alternative delivery system. In cases where a nonparticipating
provider does not accept assignment of benefits.
(5) By report.
Dental procedures
which are authorized as benefits only in unusual circumstances requiring
justification of exceptional conditions related to otherwise authorized
procedures. These services are further defined in paragraph (e)
of this section.
(6) Contingency operation.
Defined in 10 U.S.C. 101(a)(13)
as a military operation designated as a contingency operation by
the Secretary of Defense or a military operation that results in
the exercise of authorities for ordering Reserve Component members
to active duty without their consent and is therefore automatically
a contingency operation.
(7) Cost-share.
The amount of money for which
the beneficiary (or active duty, Selected Reserve or Individual
Ready Reserve member) is responsible in connection with otherwise
covered dental services (other than disallowed amounts) as set forth
in paragraph (e) of this section. A cost-share may also be referred
to as a “co-payment.”
(8) Defense Enrollment Eligibility Reporting System
(DEERS).
The
automated system that is composed of two (2) phases:
(i) Enrolling
all active duty, Reserve and retired service members, their dependents,
and the dependents of deceased service members; and
(ii) Verifying
their eligibility for health care benefits in the direct care facilities
and through the TDP.
(9) Dental hygienist.
Practitioner in rendering
complete oral prophylaxis services, applying medication, performing
dental radiography, and providing dental education services with
a certificate, associate degree, or bachelor’s degree in the field,
and licensed by an appropriate authority.
(10) Dentist.
Doctor of Dental
Medicine (D.M.D.) or Doctor of Dental Surgery (D.D.S.) who is licensed to
practice dentistry by an appropriate authority.
(11) Diagnostic services.
Category of
dental services including:
(i) Clinical oral examinations;
(ii) Radiographic
examinations; and
(iii) Diagnostic laboratory
tests and examinations provided in connection with other dental procedures
authorized as benefits of the TDP and further defined in paragraph
(e) of the section.
(12) Endodontics.
The etiology,
prevention, diagnosis, and treatment of diseases and injuries affecting the
dental pulp, tooth root, and periapical tissue as further defined
in paragraph (e) of this section.
(13) Initial determination.
A formal written
decision on a TDP claim, a request for TDP benefit pre-determination,
a request by a provider for approval as an authorized provider,
or a decision suspending, excluding or terminating a provider as
an authorized provider under the TDP. Rejection of a claim or pre-determination,
or of a request for benefit or provider authorization for failure
to comply with administrative requirements, including failure to
submit reasonably requested information, is not an initial determination.
Responses to general or specific inquiries regarding TDP benefits
are not initial determinations.
(14) Nonparticipating
provider.
A
dentist or dental hygienist that furnished dental services to a
TDP beneficiary, but who has not agreed to participate in the contractor’s
network and accept reimbursement in accordance with the contractor’s
network agreement. A nonparticipating provider looks to the beneficiary
or active duty, Selected Reserve or Individual Ready Reserve member
for final responsibility for payment of his or her charge, but may
accept payment (assignment of benefits) directly from the insurer
or assist the beneficiary in filing the claim for reimbursement
by the dental plan contractor. Where the nonparticipating provider
does not accept payment directly from the insurer, the insurer pays
the beneficiary or active duty, Selected Reserve or Individual Ready
Reserve member, not the provider.
(15) Oral and maxillofacial
surgery.
Surgical
procedures performed in the oral cavity as further defined in paragraph
(e) of this section.
(16) Orthodontics.
The supervision,
guidance, and correction of the growing or mature dentofacial structures,
including those conditions that require movement of teeth or correction
of malrelationships and malformations of their related structures
and adjustment of relationships between and among teeth and facial
bones by the application of forces and/or the stimulation and redirection
of functional forces within the craniofacial complex as further
defined in paragraph (e) of this section.
(17) Participating
provider.
A
dentist or dental hygienist who has agreed to participate in the contractor’s
network and accept reimbursement in accordance with the contractor’s
network agreement as the total charge (even though less than the
actual billed amount), including provision for payment to the provider
by the beneficiary (or active duty, Selected Reserve or Individual
Ready Reserve member) or any cost-share for covered services.
(18) Party to the
initial determination.
Includes the TDP, a beneficiary of the TDP
and a participating provider of services whose interests have been
adjudicated by the initial determination. In addition, provider
who has been denied approval as an authorized TDP provider is a
party to the initial determination, as is a provider who is suspended,
excluded or terminated as an authorized provider, unless the provider
is excluded or suspended by another agency of the Federal Government,
a state, or a local licensing authority.
(19) Periodontics.
The examination,
diagnosis, and treatment of diseases affecting the supporting structures
of the teeth as further defined in paragraph (e) of this section.
(20) Preventive services.
Traditional
prophylaxis including scaling deposits from teeth, polishing teeth, and
topical application of fluoride to teeth, as well as other dental
services authorized in paragraph (e) of this section.
(21) Prosthodontics.
The diagnosis,
planning, making, insertion, adjustment, refinement, and repair
of artificial devices intended for the replacement of missing teeth
and associated tissues as further defined in paragraph (e) of this
section.
(22) Provider.
A dentist, dental
hygienist, or certified and licensed anesthetist as specified in paragraph
(f) of this section. This term, when used in relation to OCONUS
service area providers, may include other recognized professions
authorized to furnish care under laws of that particular country.
(23) Restorative
services.
Restoration
of teeth including those procedures commonly described as amalgam
restorations, resin restorations, pin retention, and stainless steel
crowns for primary teeth as further defined in paragraph (e) of
this section.
(d) Premium sharing--
(1) General.
Active duty,
Selected Reserve or Individual Ready Reserve members enrolling their
eligible dependents, or members of the Selected Reserve or Individual
Ready Reserve enrolling themselves, in the TDP shall be required
to pay all or a portion of the premium cost depending on their status.
(i) Members required
to pay a portion of the premium cost.
This premium category includes
active duty members (under a call or order to active duty that does
not specify a period of thirty (30) days or less) on behalf of their
enrolled dependents. It also includes members of the Selected Reserve
(as specified in 10 U.S.C. 10143) and the Individual Ready Reserve
(as specified in 10 U.S.C. 10144(b)) enrolled on their own behalf.
(ii) Members required
to pay the full premium cost.
This premium category includes members of
the Selected Reserve (as specified in 10 U.S.C. 10143), and the
Individual Ready Reserve (as specified in 10 U.S.C. 10144), on behalf
of their enrolled dependents. It also includes members of the Individual
Ready Reserve (as specified in 10 U.S.C. 10144(a)) enrolled on their
own behalf.
(2) Proportion of premium share.
The proportion
of premium share to be paid by the active duty, Selected Reserve
and Individual Reserve member pursuant to paragraph (d)(1)(i) of
this section is established by the ASD(HA), or designee, at not
more than forty (40) percent of the total premium. The proportion
of premium share to be paid by the Selected Reserve and Individual
Reserve member pursuant to paragraph (d)(1)(ii) of this section
is established by the ASD(HA), or designee, at one hundred (100)
percent of the total premium.
(3) Provision for increases in active duty, Selected
Reserve and Individual Ready Reserve member’s premium share.
(i) Although
previously capped at $20 per month, the law has been amended to authorize
the cap on active duty, Selected Reserve and Individual Ready Reserve
member’s premiums pursuant to paragraph (d)(1)(i) of this section
to rise, effective as of January 1 of each year, by the percent
equal to the lesser of:
(A) The percent by
which the rates of basic pay of members of the Uniformed Services
are increased on such date; or
(B) The sum of one-half
percent and the percent computed under 5 U.S.C. 5303(a) for the
increase in rates of basic pay for statutory pay systems for pay
periods beginning on or after such date.
(ii) Under
the legislation authorizing an increase in the monthly premium cap,
the methodology for determining the active duty, Selected Reserve
and Individual Ready Reserve member’s TDP premium pursuant to paragraph
(d)(1)(i) of this section will be applied as if the methodology
had been in continuous use since December 31, 1993.
(4) Reduction of
premium share for enlisted members.
For enlisted members in pay
grades E-1 through E-4, the ASD(HA) or designee, may reduce the
monthly premium these active duty, Selected Reserve and Individual
Ready Reserve members pay pursuant to paragraph (d)(1)(i) of this
section.
(5) Reduction of cost-shares for enlisted members.
For enlisted
members in pay grades E-1 through E-4, the ASD(HA) or designee,
may reduce the cost-shares that active duty, Selected Reserve and Individual
Ready Reserve members pay on behalf of their enrolled dependents
and that members of the Selected Reserve and Individual Ready Reserve
pay on their own behalf for selected benefits as specified in paragraph
(e)(3)(i) of this section.
(6) Premium payment method.
The active duty, Selected
Reserve and Individual Ready Reserve member’s premium share may
be deducted from the active duty, Selected Reserve or Individual
Ready Reserve member’s basic pay or compensation paid under 37 U.S.C.
206, if sufficient pay is available. For members who are otherwise
eligible for TDP benefits and who do not receive such pay and dependents
who are otherwise eligible for TDP benefits and whose sponsors do
not receive such pay, or if insufficient pay is available, the premium
payment may be collected pursuant to procedures established by the
Director, OCHAMPUS, or designee.
(7) Annual notification
of premium rates.
TDP premium rates will be determined as part
of the competitive contracting process. Information on the premium
rates will be widely distributed by the dental plan contractor and
the Government.
(f) Authorized providers--
(1) General.
Beneficiaries
may seek covered services from any provider who is fully licensed
and approved to provide dental care or covered anesthesia benefits
in the state where the provider is located. This includes licensed
dental hygienists, practicing within the scope of their licensure,
subject to any restrictions a state licensure or legislative body
imposes regarding their status as independent providers of care.
(2) Authorized provider
status does not guarantee payment of benefits.
The fact that a provider is “authorized”
is not to be construed to mean that the TDP will automatically pay
a claim for services or supplies provided by such a provider. The
Director, OCHAMPUS, or designee, also must determine if the patient
is an eligible beneficiary, whether the services or supplies billed
are authorized and medically necessary, and whether any of the authorized
exclusions of otherwise qualified providers presented in this section
apply.
(3) Utilization review and quality assurance.
Services and
supplies furnished by providers of care shall be subject to utilization
review and quality assurance standards, norms, and criteria established
under the TDP. Utilization review and quality assurance assessments
shall be performed under the TDP consistent with the nature and
level of benefits of the plan, and shall include analysis of the
data and findings by the dental plan contractor from other dental
accounts.
(4) Provider required.
In order to be considered
benefits, all services and supplies shall be rendered by, prescribed
by, or furnished at the direction of, or on the order of a TDP authorized
provider practicing within the scope of his or her license.
(5) Participating
provider.
An
authorized provider may elect to participate as a network provider
in the dental plan contractor’s network and any such election will
apply to all TDP beneficiaries. The authorized provider may not
participate on a claim-by-claim basis. The participating provide
must agree to accept, within one (1) day of a request for appointment,
beneficiaries in need of emergency palliative treatment. Payment
to the participating provider is based on the methodology specified
in paragraph (g)(2)(ii) of this section. The fee or charge determinations
are binding upon the provider in accordance with the dental plan
contractor’s procedures for participation in the network. Payment
is made directly to the participating provider, and the participating
provider may only charge the beneficiary the applicable percent
cost-share of the dental plan contractor’s allowable charge for
those benefit categories as specified in paragraph (e) of this section,
in addition to the full charges for any services not authorized
as benefits.
(6) Nonparticipating provider.
An authorized provider may
elect to not participate for all TDP beneficiaries and request the
beneficiary or active duty, Selected Reserve or Individual Ready
Reserve member to pay any amount of the provider’s billed charge
in excess of the dental plan contractor’s determination of allowable
charges (to include the appropriate cost-share). Neither the Government nor
the dental plan contractor shall have any responsibility for any
amounts over the allowable charges as determined by the dental plan
contractor, except where the dental plan contractor is unable to identify
a participating provider of care within thirty-five (35) miles of
the beneficiary’s place of residence with appointment availability
within twenty-one (21) calendar days. In such instances of the nonavailability
of a participating provider and in accordance with the provisions
of the dental contract, the nonparticipating provider located within
thirty-five (35) miles of the beneficiary’s place of residence shall
be paid his or her usual fees (either by the beneficiary or the
dental plan contractor if the beneficiary elected assignment of
benefits), less the percent cost-share as specified in paragraph (e)(3)(i)
of this section.
(i) Assignment of benefits.
A nonparticipating provider
may accept assignment of benefits for claims (for beneficiaries
certifying their willingness to make such assignment of benefits)
by filing the claims completed with the assistance of the beneficiary
or active duty, Selected Reserve or Individual Ready Reserve member
for direct payment by the dental plan contractor to the provider.
(ii) No assignment
of benefits.
A
nonparticipating provider for all beneficiaries may request that
the beneficiary or active duty, Selected Reserve or Individual Ready
Reserve member file the claim directly with the dental plan contractor,
making arrangements with the beneficiary or active duty, Selected Reserve
or Individual Ready Reserve member for direct payment by the beneficiary
or active duty, Selected Reserve or Individual Ready Reserve member.
(7) Alternative delivery
system--
(i) General.
Alternative
delivery systems may be established by the Director, OCHAMPUS, or
designee, as authorized providers. Only dentists, dental hygienists
and licensed anesthetists shall be authorized to provide or direct
the provision of authorized services and supplies in an approved
alternative delivery system.
(ii) Defined.
An alternative
delivery system may be any approved arrangement for a preferred provider
organization, capitation plan, dental health maintenance or clinic
organization, or other contracted arrangement which is approved
by OCHAMPUS in accordance with requirements and guidelines.
(iii) Elective or
exclusive arrangement.
Alternative delivery systems may be established
by contract or other arrangement on either an elective or exclusive
basis for beneficiary selection of participating and authorized
providers in accordance with contractual requirements and guidelines.
(iv) Provider election
of participation.
Otherwise authorized providers must be provided
with the opportunity of applying for participation in an alternative
delivery system and of achieving participation status based on reasonable
criteria for timeliness of application, quality of care, cost containment,
geographic location, patient availability, and acceptance of reimbursement
allowance.
(v) Limitation on authorized providers.
Where exclusive
alternative delivery systems are established, only providers participating
in the alternative delivery system are authorized providers of care.
In such instances, the TDP shall continue to pay beneficiary claims
for services rendered by otherwise authorized providers in accordance
with established rules for reimbursement of nonparticipating providers
where the beneficiary has established a patient relationship with
the nonparticipating provider prior to the TDP’s proposal to subcontract
with the alternative delivery system.
(vi) Charge agreements.
Where the alternative
delivery system employs a discounted fee-for-service reimbursement
methodology or schedule of charges or rates which includes all or
most dental services and procedures recognized by the American Dental
Association’s Council on Dental Care Program’s Code on Dental Procedures
and Nomenclature, the discounts or schedule of charges or rates
for all dental services and procedures shall be extended by its
participating providers to beneficiaries of the TDP as an incentive
for beneficiary participation in the alternative delivery system.
(g) Benefit payment--
(1) General.
TDP benefits
payments are made either directly to the provider or to the beneficiary
or active duty, Selected Reserve or Individual Ready Reserve member,
depending on the manner in which the claim is submitted or the terms
of the subcontract of an alternative delivery system with the dental
plan contractor.
(2) Benefit payment.
Beneficiaries are not required
to utilize participating providers. For beneficiaries who do use
these participating providers, however, these providers shall not
balance bill any amount in excess of the maximum payment allowed
by the dental plan contractor for covered services. Beneficiaries
using nonparticipating providers may be balance-billed amounts in
excess of the dental plan contractor’s determination of allowable
charges. The following general requirements for the TDP benefit
payment methodology shall be met, subject to modifications and exceptions
approved by the Director, OCHAMPUS, or designee:
(i) Nonparticipating
providers (or the Beneficiaries or active duty, Selected Reserve
or Individual Ready Reserve members for unassigned claims) shall
be reimbursed at the lesser of the provider’s actual charge: Or
the network maximum allowable charge for similar services for that
same locality (region) or state, whichever is lower, subject to
the exception listed in paragraph (e)(3)(ii) of this section, less
any cost-share amount due for authorized services. The network maximum
allowable charge is the maximum negotiated fee between the dental
contractor and any TDP participating provider for similar services
covered by the dental plan in that same locality (region) or state.
(ii) Participating
providers shall be reimbursed in accordance with the contractor’s
network agreements, less any cost-share amount due for authorized
services.
(3) Fraud, abuse, and conflict of interest.
The provisions
of Sec. 199.9 shall apply except for Sec. 199.9(e). All references
to “CHAMPUS contractors”, “CHAMPUS beneficiaries” and “CHAMPUS providers” in
Sec. 199.9 shall be construed to mean the “dental plan contractor”,
“TDP beneficiaries” and “TPD providers” respectively for the purposes
of this section. Examples of fraud include situations in which ineligible
persons not enrolled in the TDP obtain care and file claims for
benefits under the name and identification of a beneficiary; or
when providers submit claims for services and supplies not rendered to
Beneficiaries; or when a participating provider bills the beneficiary
for amounts over the dental plan contractor’s determination of allowable
charges; or when a provider fails to collect the specified patient cost-share
amount.
[66 FR 12860, Mar 1, 2001; 66 FR 16400, Mar
26, 2001, as amended at 68 FR 65174, Nov 19, 2003; 69 FR 55359,
Sep 14, 2004; 70 FR 55252, Sep 21, 2005; 71 FR 1696, Jan 11, 2006;
71 FR 31943, Jun 2, 2006; 71 FR 66872, Nov 17, 2006; 72 FR 53685,
Sep 20, 2007; 76 FR 57643, Sep 16, 2011; 76 FR 81367, Dec 28, 2011;
80 FR 55254, Sep 15, 2015; 81 FR 11667, Mar 7, 2016]